WRIST/HAND PATHOLOGY

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Orthopaedic Manual Physical Therapy Series 2017-2018

Orthopaedic Manual Physical Therapy SeriesCharlottesville 2017-2018

WRIST/HAND PATHOLOGY

Kristin Kelley, DPT, OCS, FAAOMPT

Orthopaedic Manual Physical Therapy Series 2017-2018 www.vompti.com

Trauma/Fractures

• Hook of Hamate Fractures

• Triangular Fibrocartilage Complex (TFCC)

• Distal Radius Fractures

• Boxer’s Fracture

• Scaphoid Fracture

• Mallet Finger

• Jersey Finger


Hook of Hamate Fracture

• History– Common in bat, raquest,

stick sports

– Direct trauma to palm

– Bad golf swing

– Ulnar wrist pain

• Physical Exam– Pain with gripping

– (+) TTP Hook of Hamate

– Pain with resisted 4th/5th

DIP Flexion with Wrist Flexion and UD

• Differential Diagnosis

– Wrist Sprain

– TFCC Tear

– Ulnar Neuritis

– Ganglion Cyst

• Treatment

– Conservative – cast x 12 weeks

– Surgical – Excision > ORIF


TFCC Injury

• History– FOOSH, Ulnar Distraction,

Repetitive axial Loading

– Ulnar-sided wrist pain

– Click/crepitus with forearm rotation, gripping, ulnar dev.

• Physical Exam– (+) TTP TFCC

– Press Test (Sn = 100%)

– TFCC Grind Test• “Click” with Flex/Ext in

UD

• Differential Diagnosis– ECU tendon subluxation

– Lunotriquetral pathology

• Treatment– Brace 4-6 weeks




TFCC Tests

• Press Test • Grind Test – https://www.youtube.com/

watch?v=I6LedAdjnN0


Distal Radius Fracture

• Colles’ Fracture– Dorsal Displacement

– Extra-Articular

• Smith’s Fracture– Volar Displacement

– Extra-Articular

• Barton’s Fracture– Volar or Dorsal

Displacement

– Intra-Articular


Boxer’s Fracture• History

– Pain to fx site, dorsal swelling, deformity

– Mechanism: direct impact to MC shaft/head

• Physical Exam– Rotational malalignment

in flexion

– Decreased MC height

– Loss of MCP/PIP Extension

• Differential Diagnosis– Contusion

– MCP Dislocation

• Treatment– Splinting

– Non-operative >90% prognosis


Scaphoid Fracture/Instability• History

– Most frequently fxcarpal bone bcscaphoid links prox and distal rows

– Fx upon falling in ext/supination (backward onto hand)

• Physical Exam

– (+) axial compression of thumb vs scaphoid

– (+) Scaphoid shift/Watson test

• Differential Diagnosis– Thumb CMC Arthritis– DeQuervain’s

Tenosynovitis– Radial Styloid Fracture– Intersection Syndrome– Superficial Radial Sensory

Nerve

• Treatment– **Decreased blood supply

so waiting to treat could lead to necrosis

– If x-ray (-), immobilize x 2 weeks then re-xray or bone scan

https://www.youtube.com/watch?v=I6LedAdjnN0




Scaphoid Fracture/Instability

• Diagnosis

– Axial Load of Thumb

– Scaphoid Shift/Watson’s Test

• Dorsal directed pressure on scaphoid as wrist moves from UD to RD. (+) if relocating clunk as scaphoid flexes and strikes radius


Other FOOSH Injuries at Wrist

• Supination + RD = Scaphoid

• Supination + UD = Lunotriquitral

• Pronation with central wrist pain = Carpal Instability (Scapholunate or Lunotriquitral)

• Pronation + UD = TFCC Tear

Mallet Finger

• History– Avulsion of distal slip of

extensor tendon

– Rapid forced flexion of distal phalanx

• Physical Exam– Dec. DIP Ext AROM

– PROM DIP Ext WNL

– (+) TTP Dorsal Dip

• Treatment– Splint full ext 6-8 weeks


Jersey Finger

• History– Commonly missed

– Pain in finger/palm

– 4th finger most common

– Mechanism: forced finger extension against active flexion

• Physical Exam– Loss of DIP AROM

– Fingertip cannot touch palm with fist

• Differential Diagnosis– PIP/DIP Fracture/Dislocation




DeQuervain’s Tenosynovitis• History

– Most common overuse injury of hand

– Common activities of forceful grip + UD (tennis serve)

– Pain dorsal/radial wrist along 1st dorsal compartment w/ROM

• Physical Exam– (+) Finkelstein’s Test– Painful RSC Thumb Extension

– TTP APL/EPB tendons, radial styloid, swelling, thickening


DeQuervain’s Tenosynovitis

• Finkelstein’s Test

– Flex the thumb into the

palm and close the

fingers around the

thumb

– Ulnar deviate the wrist

– Positive test results in

pain at the 1st dorsal

compartment

– Sn 100%, Sp 100%


DeQuervain’s Tenosynovitis


– Thumb CMC Arthritis

– Scaphoid Fracture

– Radial Styloid Fracture

– Intersection Syndrome

• Compartment II over I

– Superficial Radial Sensory Nerve

• Treatment

– Thumb spica splint worn 2 weeks and at night 6-8 weeks


Intersection Syndrome

• History

– Pain/swelling at radial wrist where 1st/2nd dorsal compartments meet due to inflammation of wrist extensors vs. APL and EPB

– Mechanism: repetitive grip w/thumb abd activity (rowing, racket use, pulling rake vs. ground, holding ski poles)

• Physical Exam

– TTP radial wrist at site of 1st/2nd dorsal compartments

– Crepitus with thumb and wrist ROM




Intersection Syndrome


– Thumb CMC Arthritis

– Scaphoid Fracture

– Radial Styloid Fracture

– De Quervain’s Syndrome

– Superficial Radial Sensory Nerve Injury

• Treatment

– PT for education of activity modification, treatments for reducing inflammation

– NSAIDS

– Thumb Spica

– Surgical Release


Lateral Wrist Pain


Guyon’s Canal Entrapment

• Compression of Ulnar nerve in canal formed between Pisiform and Hamate

• Ulnar Nerve

• Ulnar Artery

• Often involves Deep motor branch > sensory branch

• (+) Froment’s Sign


Trigger Finger

• History– Finger pain/locking

– Clicking at pam upon finger flex/ext

• Objective

– TTP at flexor tendon

– Palpable nodule at tendon sheath w/AROM flex/ext




Common Deformities and Injuries

• Keinbock’s Disease– AVN of Lunate

– Associated with Negative Ulnar Variance



• Swan-Neck Deformity– DIP Flexion and PIP

Extension

– Typically Requires Surgical Intervention

– Lateral band slips dorsally



• Boutonniere Deformity

– DIP Hyperextension and PIP Flexion

– Responds well to splinting and exercise

– Lateral band slips volarly



• Dupuytren’s Contracture

– Fibrous tissue in palmar/digital fascia of hand

– Flexion contracture of digits, often 4th and 5th

– Treatment – usually surgery

WRIST/HAND PATHOLOGY

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